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Executive summary Background Method Key findings Conclusions Recommendations References Appendix Special thanks

1 5 11 15 25 30 31 32 32

ExECutivE SuMMARy
introduction
imple first aid skills, and the confidence to use them, can save lives. Yet only seven per cent of British adults can correctly recall first aid advice, and feel confident and willing to give first aid (British Red Cross survey, 2009). When is the best time to start developing peoples first aid skills and attitudes to their own role in helping others? This study explores the feasibility and effectiveness of starting this process as early as possible during childrens first years at school. The project investigated the following questions: > Can children as young as five learn first aid skills? > What first aid knowledge and skills can pupils aged five/six, seven/eight and nine/ten learn and in what way? > Can children retain this knowledge/skill? > Can any indication be gained as to how confident, able and willing to act in an emergency situation children would be, after being taught first aid? It is clear from European studies that children as young as six can learn and retain first aid skills. However a number of variables might affect this, and are worthy of further investigation namely, the type of skill retained and the feasibility of teachers delivering lessons in school. Nineteen per cent of European countries have compulsory first aid education in their schools. The UK is not one of them. Norway is and reports that 95 per cent of its population is first aid trained (First aid for a safer future IFRC report 2009). As stated above the UK compares dismally with this in terms of reported ability, confidence and willingness to give first aid. A British Red Cross survey of primary schools in the UK (August 2010) found that only 18 per cent currently taught first aid but 83 per cent of teachers supported first aid teaching for their pupils. First aid has many advantages as a topic to learn in primary schools. Most children have personally experienced minor bumps or burns, or even more major ones. The subject is hugely motivating and can be used as a vehicle to develop other skills like literacy.

riGht place, riGht time First aid education in primary schools

This study examines: > First aid learning lead by the classroom teacher over 2/3 sessions. > Learning at three ages in the early, middle and later years of primary school. > Skills retention using scenario based assessments two months later. It was undertaken in nine schools across the UK, including 25 classes and around 625 children. The materials produced for the teachers were based on the new British Red Cross teaching programme, everyday first aid. The approach is to emphasise the outcome of the intervention and simplify the skills taught. The concept is to present the clinically accurate core of first aid through delivering simple messages. This approach is embedded within the British Red Cross Life. Live it. teaching resource for primary schools, developed in parallel to this research.

actions to reduce pain or even save a life can be learned throughout a childs time at school with relatively little investment of time. Children can not only learn first aid from the age of five but enjoy learning it. The topics covered in the research were appropriate for the age groups. The topics were taught within the context of caring and supporting others. Those covered in the earlier years burns and emergency calls are straight forward and were learned effectively. The straight forward nature of the treatment for nosebleeds would suggest that this is another topic suitable for children aged five upwards. The majority of children could remember how to call the emergency services, and treat burns, choking and severe bleeds. Many of those that forgot the steps to take when initially presented with the mock scenarios did remember with slight prompting e.g. by the roleplaying emergency operator. They were then able to confidently take steps that children who had not been taught first aid did more hesitantly and less effectively.

Dial 999
for an ambulance
redcross.org.uk/firstaid
The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949) and Scotland (SC037738).

Figure 1 poster for children aged five to six years Calling the emergency services: The vast majority of children from the age of five were able to develop these skills. This demonstrates that the ability to make a call to the emergency services opens a considerable support mechanism to a child. Given the permission to do so and the information of when and how to do it gives the child the confidence to phone. This will increase the resilience of the child considerably. Helping an unconscious casualty: The nine to ten-year-old children took more appropriate actions than their younger classmates when dealing with a roleplaying unconscious casualty, possibly because of their greater understanding of breathing and unconsciousness. Findings from the limited control group indicate that unless children are taught about unconsciousness at school they are not going to be aware of the simple interventions that need to be taken to save a life. Choking: This is another situation that children can learn the appropriate intervention. Along with severe bleeding this research shows it to be a suitable topic for the middle and later years of primary education.

What children can learn

All the age groups retained first aid skills and knowledge to a large extent, whether it was to put an unconscious person on their side, apply pressure to a severe bleed or phone 999. This shows that simple

table 1 topics taught to the children of different ages age of children topic Five to six checking that an area is safe. alerting an adult and phoning the emergency services. causes of burns and their treatment. alerting an adult and phoning the emergency services. causes of burns and their treatment. recognition and treatment of unconsciousness. recognition and treatment of unconsciousness. alerting an adult and phoning the emergency services. the importance of keeping calm and treatment of nosebleeds, severe bleeding and choking.

seven to eight

nine to ten

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the feasibility of teaching first aid at primary school

The children, the teachers and the parents involved in the research considered first aid to be highly relevant. The evidence indicates that by teaching the children first aid there may be an influence on the skills and attitudes of a wider group including family members. All the nine schools involved in the study are planning to teach the topics again the following year, now they have teaching resources and have seen the value of the learning to the children. This study shows that classroom teachers can deliver the key first aid messages effectively and with imagination, but need carefully designed resources to enable them, and encourage them, to

do so. Although the primary school curriculum is packed with many subjects, the relevance and flexibility of first aid allows it to be both incorporated into other subjects and learned as a stand-alone topic over relatively short periods of time. Teachers and parents expressed the view that the first aid skills should be reinforced and progressed throughout a childs school career.

4. All children should be taught how and when to phone the emergency services as soon as possible. 5. Teachers should be able to access first aid teaching materials. 6. Teachers should be able to access support to increase confidence to teach first aid. 7. First aid should be included in the statutory primary curricula in England, Northern Ireland, Scotland and Wales.

Recommendations
1. Simple first aid should be taught to all ages. 2. First aid should be as natural a part of life as counting. 3. Simple first aid messages should be reinforced and childrens confidence developed over their time in primary school. 3

riGht place, riGht time First aid education in primary schools

riGht place, riGht time First aid education in primary schools

BACKGROuND
purpose of report
imple first aid skills, and the confidence to use them, can save lives. Yet only seven per cent of British adults can correctly recall first aid advice, and feel confident and willing to give first aid (British Red Cross survey, 2009). Confidence and willingness are just as important as the actual skills even when people have first aid skills, studies show that the more people that are around a person who could benefit from first aid, the less likely someone is to step in and help (the bystander effect, Darley and Latan 1968). The UK has high levels of skill and technology to support recovery when a person reaches medical aid. However, in accident and emergency medicine, early intervention is key, whether that is emergency care or simply phoning 999. In situations such as the severe winters of 2009-10 and 2010-11, when many parts of the country were cut off from fast emergency support, it is vital that these skills and characteristics are embedded within communities. When is the best time to start developing peoples first aid skills and attitudes to their own role in society? This study explores the feasibility and effectiveness of starting this process as early as possible during childrens first years at school. The project investigated the following questions: > Could children as young as five learn first aid skills? > What knowledge and skills could pupils aged five/six, seven/eight and nine/ten learn and in what way? > Could children retain this knowledge/skill? > Could and would classroom teachers teach first aid? > Could any indication be gained as to how confident, able and willing to act in an emergency situation children would be after being taught first aid?

riGht place, riGht time First aid education in primary schools

British Red cross recent developments and present practice

Even with the passion that many members of the British Red Cross and other organisations have to train young people in first aid, it is not possible to reach a very high percentage of children in this way. Many more can be reached, in theory virtually all children, if first aid was taught by the school teacher as a normal part of the curriculum. The British Red Cross has recently begun to place a strong focus on the educational aspects of learning first aid. A new programme, called everyday first aid, is being introduced to help anyone learn first aid. The approach is to emphasise the outcome of the intervention and simplify the skills taught. The concept is to present the clinically accurate core of first aid through delivering simple messages. The benefits of this approach are that it enables flexibility in the depth of knowledge given to the learner and the content can be varied to fit the specific needs of the group. The aim of this educational approach is to improve skill acquisition and retention so that they can be used when required. This approach, together with appropriate resources, can enable a variety of educators to pass on the basic messages, including the childrens teacher. It is commonly reported by people receiving first aid training from the British Red Cross, that they are worried by giving first aid in case they do it wrong or in the wrong order. We believe that by concentrating on a few very simple messages, learners should be more confident that they can achieve the appropriate outcome. The British Red Cross has hundreds of volunteers and staff that go into schools and other venues to teach first aid. We can therefore distinguish three main 6

ways of delivering first aid knowledge and skills: > Taught by first aid trainers/ educators from outside organisations in school > Taught by first aid trainers/ educators from other organisations in venues outside school > Taught by the classroom teacher in school. Evaluations of the teaching delivery of the former two types shed light on the ability of children to learn first aid knowledge and skills. Paul Bradshaw, Humanitarian education officer, and the British Red Cross in Shropshire evaluated Crucial Crew venues delivery of first aid training. Crucial Crew venues deliver a small portion of first aid training to thousands of ten to 11-year-old children, throughout England and Wales. The venues are run by a variety of organisations e.g. fire service, Rotary Club. Children learn about various aspects of safety by undertaking activities at about ten stations in the venue. Around 15 minutes are spent learning basic first aid e.g. what to do after a cycle accident. The evaluation found that the confidence to act of the ten to 11-year-olds attending the sessions increased markedly. Pupils saw themselves as the key person to make a place safe and one week after the session had sufficient recall of skills to put a person into the recovery position. This evaluation of a very short course of first aid skills indicates both confidence of using skills and short-term retention. What remains unknown is whether the skills were retained for a longer period than one week, and whether increasing the length and volume of training had any effects upon skills retention. The Avonsafe Project in Bristol taught over 3,000 year six pupils

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(aged ten to 11 years) in 2010. The topics covered in a twohour session were: checking for breathing, 999 calls (which most of the children will have covered in a previous session at the Bristol Lifeskills safety education centre) burns, choking and treatment for unconsciousness. In the evaluation of this project, teachers were asked to give the pupils a test before and after the training, in the form of a Who Wants to be a Millionaire? style quiz. The post-test took place two months after the session. The evaluation found that 56.5 per cent of children knew the correct treatment for burns before the session whereas two months afterwards the figure had risen to 93.7 per cent. The equivalent figures for choking were three per cent (pre) and 78.6 per cent (post). Clearly, in these areas, these children were not only learning these topics but also retaining the information for a longer period. The difficult problem of trying to ascertain whether the children would act in an emergency was tackled with the question How happy would you be to use your new first aid skills? Fifty-nine per cent replied yes with a further 34 per cent saying a bit. This

demonstrates that confidence to act was positive. The previous evaluations clearly demonstrate retention, albeit over differing timescales, of first aid skills in children aged ten to 11. Wayne Morgan and colleagues in Wales (2006), undertook a study of their Keep Me Safe programme, a course in which first aid trainers taught nine to ten-year-old pupils for one-hour sessions. The children were tested before the sessions and given the same written test a week after the session. It was found that: > The number of children who knew to tilt their head forward rather than back when treating a nosebleed trebled from just over 30 per cent to over 90 per cent. > Immediately checking for danger at an accident also trebled but only to just over 30% after the session. > Over 90% of these older primary children knew the emergency number to call before the session and this increased even more after it. > The knowledge of the correct treatment for a cut arm massively increased from about five per cent to over 70 per cent.

These studies indicate that children in the later years of primary school can learn treatments for burns, choking and bleeding. The written tests indicate that learning has taken place. Less clear is whether this learning can be put into practice. Indeed, it is also difficult to interpret whether those children answering a test question incorrectly did not retain this information or whether the information was ever learned in the first place. Life. Live it. for young people is a British Red Cross first aid education resource for secondary schools. Although there has been no specific research the feedback from teachers has demonstrated effective learning of a range of first aid topics.

Background and previous studies

Every single day in the UK there are more than 2,600 open wound injuries, 2,400 bone injuries, 290 injuries from burns and almost 40 incidents of choking. Around one third of these are children under 15 years old, with 44 per cent of burn injuries being in this age group. Knowledge of first aid could help

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reduce injury and even save lives. The British Red Cross report Life. Live it. The case for first aid education in UK schools (2006) put forward eight essentials that every young person should learn, wherever they live in the UK. These were: 1. Dealing with accidents 2. Unconsciousness and resuscitation 3. Choking 4. Bleeding and shock 5. Burns and scalds 6. Specific injuries 7. Specific illnesses 8. Emotional and social dimension of helping others in need

It was important to assess whether first aid teaching in the selected areas resulted in the learning and retention of skills and knowledge. In other words is it effective? The other aspect was the feasibility. Would teachers be prepared to include this topic in an already packed curriculum? An important consideration was that the demands placed on the teachers were not too great, so that the sessions could be fitted relatively easily into the curriculum. We wanted the teachers to be considering the feasibility of the permanent inclusion of first aid into the curriculum, not just a one-off research study. Two hours teaching time per teaching group was therefore requested and the materials were carefully produced to reduce the preparation time of the teachers involved.

UK primary schools would give to first aid in one year but does point to children in the later years of primary school being able to learn first aid. In Bollig, Wahl and Svendsens study in Norway a group of children aged six to seven years old were given five lessons of 45 minutes each. These were taught by a first aid instructor using a glove puppet. The lessons ranged from assessment of consciousness and breathing to bleeding and behaviour in emergency situations. In virtually all scenario tasks given at the end of the course well over 50 per cent of the children were successful. There was also a high retention of skills after six months.

Focus of this research

Children will encounter a variety of incidents which will require a variety of first aid inventions. The topics taught to the pupils during this research project were chosen from the eight essentials using the following criteria: > They involved situations that the children were most likely to encounter. > There was less research work carried out in this area of learning with this age range. A number of studies have been undertaken to investigate whether children can undertake CPR (cardio-pulmonary resuscitation) and evidence of their effectiveness in carrying out CPR collected. This research therefore did not include CPR. 8

previous europe-wide studies

Fleischhackl, Nuernberger et al.s study in Austria into whether school children aged as young as nine could successfully learn basic life support skills, found the vast majority were effective in aspects including checking for breathing, recovery position and calling the emergency services approximately four months after training. The students aged nine to 18 (average age 13) had six hours of training over three months. This is probably more time than most

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A course in Italy with children aged eight to 11 years included nosebleeds, broken teeth and paediatric basic life support (Lubrano, Romero et al.). They found that children taught with a practical element to the lessons recalled the appropriate actions significantly better than those taught with only a theoretical input. They believed that this method of teaching emergency first aid could be successful in training primary school children. What is clear from these European studies is that children as young as six can learn and retain first aid skills. However a number of variables might affect this, and are worthy of further investigation namely, the type of skill retained and the feasibility of delivering this training.

procedures and were significantly better than the controls in almost all areas of basic life support. The Heartstart observational study from their UK training programme (Jones et al, 2007) investigated the age at which schoolchildren can provide effective chest compressions and found that those aged nine to ten were not physically able to compress the chest but could learn the principles of chest compression as successfully as children aged 11 to 14. It would seem from the IMPS and Heartstart studies, that children can effectively learn the skills, even if unable to be effective in carrying them out physically.

School curricula
Nineteen per cent of European countries have compulsory first aid education in their schools. Norway is one of these, which is probably why 95 per cent of its population is first aid trained. The UK compares dismally with this. A British Red Cross survey in 2009 found just seven per cent of the population are able to correctly recall first aid advice, and feel confident and willing to carry out that advice. Another British Red Cross survey in August 2010 found that only 18 per cent of primary schools taught first aid but 83 per cent of teachers wanted it to become part of the curriculum. In the UK, each of the four countries has its own statutory curriculum. Suggestions are made, in some cases, that first aid could be taught. There are a number of references to developing resilient, caring, responsible individuals and members of the community that are aware of safety. First aid could be considered as an aspect of this. However in no country is first aid a statutory part of the curriculum.

previous UK studies
A group at Queens University Belfast, along with the Cormac Trust, developed the ABC for Life programme. In this case medical students taught schoolteachers the essential techniques of basic life support and the teachers then taught the skills to their ten to 11-year-old pupils. This programme has been successfully continued for seven years working with 300 primary schools. The UK injury minimisation programme for schools (IMPS) by Frederick et al. includes exploring all aspects of risks and safety, and aims to enable children to make better-informed decisions about risk. The programme includes some first aid skills and how and when to seek help. Aimed at children aged ten to 11, it is taught by a combination of IMPS trainers and the childrens schoolteachers. Five months after the programme the children who had the intervention were compared with those that had not. It was found that the children in the intervention group were more willing to undertake emergency life-saving

riGht place, riGht time First aid education in primary schools

is first aid an appropriate topic to teach in primary schools?

First aid has many advantages as a topic to learn in primary schools. Most children have personally experienced minor bumps or burns, or even more major ones. They therefore see the topic as relevant and are motivated to learn. The essence of familiarity also gives them something to build on. Very young children tend to put information into a visual spatial memory and first aid can be taught in this way with pictures, videos and role play. As they get older there tends to be a shift towards remembering more verbal characteristics and so descriptions can become more and more verbal alongside the visual and kinaesthetic. It can therefore be argued that, if the topics can be learned by this age group, first aid would an ideal area for the primary curriculum.

At five years old, children are developing their sense of others around them and starting to form their moral sense (Nuttall). The British Red Cross and others are trying to form a society where most people have the confidence, willingness and first aid skills to act in an emergency situation. Should we not therefore be considering supporting children, as early as possible, in developing a caring attitude to others and a humanitarian approach which includes giving first aid?
redcross.org.uk/firstaid

Burn? Cool it

This study examines: > learning lead by the classroom teacher > learning at three ages in the early, middle and later years of primary school > skills retention using scenario based assessments two months later.

The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949) and Scotland (SC037738).

Figure 2 poster for children aged five to six years

caSe StUDY
i dont know why the head has picked me i dont like blood. there was a certain reticence on the part of one teacher in this medium-sized, urban junior school. the lesson for nine/ten year olds was very practically orientated with all children practising the treatment for a nosebleed, as well as bandaging and making slings both with triangular bandages and improvising. though they found it difficult to elevate the wound, they were clear that they were aiming to get it up high and the need for pressure on the wound was well emphasised. the teacher was so involved in the learning experience for her pupils that her fear of blood appeared to have no impact. she was so pleased with the learning experience that she was going to repeat the session the following year. two months later when the sample children undertook scenarios, all remembered to press on the arm that had been cut on a broken bottle and just under 50 per cent remembered where and how to apply pressure to the bleeding nose on their fellow pupil. more difficulty was experienced remembering the position the head should be in. the teacher commented: the children loved the practical activities and were sensible. We used our internal phones to stage a real emergency call, with a teaching assistant in the staffroom acting as the emergency operator. this captured the childrens imagination they took it all very seriously! the parents were clearly impressed by what their children had learned. one commented that her son did a demonstration on me another that i received a full demonstration. We then shared the knowledge together. a parent who was a nurse working in a cardiac setting commented how important it was that members of the public had basic life support skills. she had seen several people whose lives had been saved in this way.

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MEthOD

ine schools across England, Scotland, Wales and Northern Ireland took part in the research. That encompasses 25 classes, around 625 children, 22 teachers, about ten teaching assistants and 176 parents. For a variety of educational reasons, and in some cases because of the size of the school, a number of the classes contained children of mixed ages.

procedure
The research involved: > specific teaching materials being provided for the classroom teachers > three age groups being taught first aid by their teacher. These were: five to six years old seven to eight years old nine to ten years old > classroom teachers teaching two lessons on first aid. To accommodate the shorter attention spans of the younger children the lessons were sometimes split into shorter sections > the classroom teachers, and the children, assessing the effectiveness of the learning > the researcher observing one of the two lessons to assess their effectiveness of learning. > around two months later the researcher returning and asking sample pupils to respond to scenarios that assessed their retention of knowledge and skills, and their approach to giving first aid. There were 218 pupils in the sample around a third of the total number of pupils in the taught classes. The materials came from existing British Red Cross resources, including the Life. Live it. teaching programme, and were adapted for the different age groups and for use by the classroom teachers. They consisted of lesson plans, worksheets, groupwork activities, PowerPoint presentations, videos and posters. Any practical materials needed were provided.

the sample
The geographical spread of schools ensured that schools with all four UK curricula were included. The schools represented a range of sizes, numbers of children with special educational needs, numbers of children receiving free school meals, ethnic backgrounds and urban and rural areas. riGht place, riGht time First aid education in primary schools 11

topics taught
In all cases the topics were introduced in the context of caring for, and sharing with, others. Part of the aim was to encourage responsible and supportive behaviour. The topics taught are shown on the tables below. age of children Five to six topic checking that an area is safe. alerting an adult if a situation is not safe or someone is hurt. phoning the emergency services. causes of burns and their treatment. alerting an adult if someone is hurt. phoning the emergency services. causes of burns and their treatment. recognition and treatment of unconsciousness. recognition and treatment of unconsciousness. alerting an adult if someone is hurt. phoning the emergency services. the importance of keeping calm and supporting others. treatment of nosebleeds, severe bleeding and choking.

seven to eight

nine to ten

table 2 topics taught

learning outcome

Recognise unconsciousness

treat unconsciousness

cause of burns

Severe bleed

Nosebleed

alert adult

treat burn

age 5/6 7/8 9/10

choking

Safety

999

Figure 3 When to phone 999 slide from powerpoint presentation for pupils aged five to eight

table 3 topics that were taught at the different ages There was an overlap between the topics taught to each age group to allow a comparison to be made as to the effectiveness of learning at different ages. Due to the limited schedule and budget considerations the study had to take place over two terms. The study, from planning to the completion of data collection, had to be done between January and August 2010 and this limited the extent of the study.

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ethical considerations
All parents were asked for permission for their child to be part of the study. One parent requested that their child did not participate in the lessons so separate arrangements were made for this pupil. None of the schools or children involved in the research will be identified in any way to ensure anonymity. Because of the nature of first aid there were many disclosures and recounting of experiences by the children during the lessons and these have been treated with consideration and confidentiality as appropriate.

> pupil questions The class teacher asked the pupils questions at the end of each lesson to ascertain: whether they had enjoyed the lesson whether they believed they had learned effectively whether they now dared to treat someone who had been injured in the way they had learned about. > Researcher observations A researcher observed one of the lessons in each year, at each school. This gave an idea of: the different teaching styles used the learning taking place. > parent questionnaires Questionnaires were sent home to parents after the pupils had completed their two lessons to assess: whether there was any cascading of information from the child to the family the opinion of the parent regarding first aid learning. > Retention assessments Around two months after the last lesson the researcher gave a sample of children from each class a few scenarios to assess: how much they remembered how they would react to situations based on the topics they had learned.

teacher demonstrates how to help a boy who is choking

Data collection
The main two research tools used were questionnaires and the observation of the pupils while they undertook the various scenarios two months after the lessons. > teacher questionnaires Questionnaires were given to the teachers to complete after each lesson to assess: how appropriate they thought the topics were for the age group they were teaching. how effective they believed the learning to be of each learning outcome. whether the time allocated and the materials were appropriate for the age group being taught.

Figure 4 part of the pupil answer sheet for questions

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13

caSe StUDY
i had been told to expect a couple of children whose english was limited as it was not the language they spoke at home. a hesitant child entered the library where the scenario to test recall was set up. on being told she could use anything in the room to deal with the situation presented she picked up the mobile phone and started to key in numbers. expecting the usual 999 i was surprised to see her confidently putting in a totally different number. then light dawned. are you phoning your mother? yes was the enthusiastic reply. When it was suggested she could phone 999 she did so and carefully answered most of the questions, admitting there was one she could not answer but was not phased by that. she also followed the instructions from the emergency operator checking the unconscious childs breathing and putting them on their side with their head back. When she left the room, having been congratulated on her success, she was quietly smiling to herself.

Retention assessments
Retention assessments took place in a room in the school that was not in use at that particular time e.g. library, computer room, music room. For the children aged five to six a series of hazards was set up for them to identify and say how they would act. This was followed by a pupil coming in clutching a hot metal spatula and showing the child being assessed their burn. There were various materials around which could be used for an invention or treatment e.g. bottle of water, scarf, tea towel, bandage, washing-up bowl, mobile phone. All pupils were expected to make a mock phone call to the emergency services. The children aged seven to eight were also assessed using the burn scenario, as well as a scenario in which a child became unconscious. The pupils aged nine to ten had four scenarios to deal with an unconscious child, an arm that had been badly cut on a broken bottle, a nosebleed and a choking incident. 14

The actions were registered on the four figure assessment scheme: 4. Took the appropriate action 3. Took inappropriate action 2. Took appropriate action on prompting 1. Did not act even on prompting At the end of the retention assessment all pupils were given a very positive feedback with one or two suggestions for improvement.

case a second class of seven/eight year olds in the school watched the scenarios as a whole class and then wrote down how they would respond. This gave an indication of their response but was not a completely valid comparison. In all other cases the 56 pupils in the control group were presented with the same scenarios, in exactly the same way, at exactly the same time as the group that had been taught first aid. The children who undertook the scenarios were given brief feedback at the end of their session. For those few who had not had the first aid lessons this was carefully worded and included simple learning points.

control group
Because we were assessing whether children could learn the knowledge and skills at different ages it was not strictly necessary to have a control group. It is however useful to compare those who were taught the first aid lessons to those who were not. There were also ethical and practical considerations to some pupils in a class being taught first aid and others not. The occasional opportunity did arise, for example a large school having two classes of this age group or pupils being absent from the lesson. This gave us a small group with the children aged seven to eight and nine to ten years. There was no opportunity in the case of the youngest pupils. In one

riGht place, riGht time First aid education in primary schools

KEy fiNDiNGS
he study indicates that the vast majority of children can learn simple first aid skills starting at five to six years old. The retention assessments show that all children had developed some skills and knowledge, many a considerable amount.

initial learning during the first aid lessons children aged five to six years old
Most of the children aged five to six were considered to have learned the various topics. The researcher observations were very similar. When the children themselves were asked about whether they thought they had acquired the knowledge and skills their figures came out slightly higher. Clearly the pupils were able to initially pick up the knowledge and skills. One teacher commented: The children drew from personal experiences and shared with the class very enthusiastically those which related to the topics. On at least one occasion over a third of the year 1 class had either experienced a burn or seen someone else get burned. One teacher was surprised how few of them (the children) knew to cool a burn before the lesson began.

table 4 learning outcomes achieved by pupils aged five to six as assessed by the teachers average percentage of the class that achieved the learning outcome from the teacher questionnaires 94% 80% (range 30 to 100%) 92% 86% 80% 74% (range 30 to 100%)

learning outcome Be able to spot hazards Be able to recognise the need to alert an adult Be able to distinguish injuries severe enough to call an ambulance Be able to call 999 Be able to recognise that some materials burn to know that a burn is treated by cooling it

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15

The activities used and their extent varied between schools. Comments on how much the children loved the resources, like the firemans hat and the emergency operators headset, were frequent. The initial expectation that the hats would be returned did not happen!! One school extended the role-play with more props for dressing up and different scenarios. Another said they found the role-play difficult. The classes in each year group varied tremendously in experience of different types of learning, first aid incidents and ability. This was also true of individuals within the class. A couple of children had an all too vivid memory of the house fire following a candle being left burning. Observation of the groups showed it was important, particularly with the younger ages, to adapt the sessions to fit the needs of the specific children within the group. The skill of the classroom teacher to do this, in the classes observed, was superb.

As would be expected, at this age, very few children were able to tell the time. The concept of holding a burn under the cold water tap for ten minutes was therefore conveyed in a mixture of ways including singing the school song and the second school song twice and then counting down. Over 90 per cent of the children stated they had enjoyed the lesson and the teachers and observer registered similar percentages. The vast majority of the pupils were fully involved in the lesson (over 90 per cent). Virtually all teachers of the youngest age group split the lessons so they took place over four to eight sessions to accommodate the short attention span of this age group.

Teacher comments and experiences

The children drew from personal experience and shared with the class very enthusiastically those which related to the topics. On at least one occasion over a third of a class of five/six year olds had either experienced a burn or seen someone else get burned. I was surprised how few of the children knew to cool a burn before the lesson began. The children really enjoyed learning to make a 999 call.I found this interesting as the majority of the class couldnt answer the operators questions at the beginning of the lesson.

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Figure 5 (left) eight year old pupils writing and picture about calling the emergency services Figure 6 (top, background) cut, sequence and colour poster produced by child with english as an additional language Figure 7 (top, bottom right) slide from powerpoint presentation for pupils aged five to eight

initial learning during the first aid lessons children aged seven to eight and nine to ten years old
Of the pupils aged seven to eight and nine to ten over 96 per cent enjoyed and were involved in the lessons according to the teachers. Between 88 and 99 per cent of the children picked the green smiley man to indicate their enjoyment of the four lessons. For pupils aged seven to eight, the knowledge they should alert an adult if there was a problem rose to 96 per cent after the sessions and most were now able to answer the first questions in an emergency call with relative ease. There was however little difference in the percentage who had learned how to treat a burn. Though this was high in the early year at 74 per cent it was very similar at 76 per cent when the pupils were two

years older. The range had reduced but was still large, from 50 to 100 per cent. One pupil was confident enough after his lessons to tell his uncle what to do when he burned himself on a kettle. Knowing to keep the burn under cold water for ten minutes was learned by only around 50 per cent of the children with the range starting at less than 15 per cent to an upper level of around 75 per cent. This had not been a learning outcome for the younger children but was found to be difficult at age seven to eight when the ability to tell the time is still not established in some children.

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learning outcome pupils able to recognise that if someone is not moving and responding they may not be in a safe position pupils able to put an unconscious person on their side with their head back recognition that if someone is unconscious an adult needs to be alerted/999 phoned.

aGed seven to eiGht average percentage of the class that achieved the learning outcome from the teacher questionnaires 80%

aGed nine to ten average percentage of the class that achieved the learning outcome from the teacher questionnaires 78%

86%

88%

96%

96%

table 5 learning about unconsciousness at ages seven to eight and nine to ten The research material included the DRAB (danger, response, airway, breathing) check. The pupils, particularly those aged seven to eight years, loved learning a DRAB song with actions and tunes that they made up. The teachers believed that 80 per cent of the younger age group learned this topic and 88 per cent in the older age group. average percentage of the class that achieved the learning outcome from the teacher questionnaires 80% 76%

Teacher comments
I was surprised how well the children could list things that could burn sparklers, fireworks, chemicals. Children really enjoyed role playing the emergency operator.. it was useful having the questions on the PowerPoint to prompt the children. The card sort for the burn was interesting as we discovered not just one correct order so demonstrating good thinking and reasoning skills. The experiences of burns the pupils recounted were quite an eye-opener. We made posters to reinforce the information which was a good way of helping the children with English as an additional language to remember. (see Figure 6)

learning outcome pupils know how to treat a nosebleed pupils know they need to apply pressure to a severe bleed and how to do so pupils know how to treat a person who is choking by hitting them on the back

90%

table 6 learning about nosebleeds, severe bleeds and choking at age nine to ten

Figure 8 Worksheet on unconsciousness 18 riGht place, riGht time First aid education in primary schools

Teachers of pupils aged seven to eight

The video clip was useful for the children to watch, so they could see how to put someone in the recovery position. The role-play was good it is easier to remember when you do something kinaesthetic. A follow-up lesson to remind pupils about the correct position would be useful.

Figure 9 do you think you would act? pupil responses (unconsciousness)

100
Yes

Percentage of Pupils

80 60 40 20

maybe No

Teachers of pupils aged nine to ten

We used our internal phones to stage a real emergency call. This captured the childrens imagination they took it very seriously! Checking the airway had to be reinforced and the rationale explained. The lesson did run over time and the pupils were keen to discuss the lesson afterwards when we went back to the classroom!

7/8 years

9/10 years

Age of Pupil
The second lesson for nine to tenyear-olds involved treatment for nosebleeds, severe bleeding and choking. In the observed lessons some of the pupils thought initially that you put your head back when you had a nosebleed and press high up on the bridge of the nose. In most cases the teacher got the whole of the class to demonstrate the correct treatment. This was a fairly brief part of the lesson. The percentage of pupils who knew how to treat choking only applies to those taught because a number of teachers found lesson too long in a number of cases and did not mention choking. In all cases and in all years the teachers considered the topics covered appropriate for their pupils. whether they felt they would help (see method page 13). This belief was retained for the same topic in the seven to eightyear-olds; however, only 80 per cent of this age group said the same about treating unconsciousness. Nine to tenyear-olds were even less confident they would act to treat unconsciousness. The four children that circled orange in one nine/ten year old class on unconsciousness all later went up to their teacher to explain their reasons clearly. It appeared that they felt they should help but were worried that the casualty might be lying to me or be a druggie. Even if the belief that they felt they should help is not translated into action, the belief is something to build on. The second lesson for the nine to ten-year-olds was on bleeds and choking and the figures were similar to the first unconsciousness lesson with 59 per cent.

Pupil comments
I did like this lesson because its very important to know! I wasnt shaw about doing it in real life. I would like to do this lesson again. I enjoyed this lesson because it was fun to learn about first aid. I have circled most of the green blobs because I feel I can do them for real. I enjoyed this lesson because I got to learn really important things that you will do in life.

pupils feelings about whether they would take action

The pupils aged five to six firmly believed that they would act in an emergency. Over 90 per cent ticked the green smiley man and none the red man when asked

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Retention assessment
Around two months after the pupils were taught the first aid topics, 64 children aged five to six, 73 aged seven to eight and 81 aged nine to ten, were presented with individual scenarios, in which a classmate needed help, to see how they would react. Of the 218 children, only one did not help the injured pupil. Many were hesitant and nervous but all the others attempted to help in some way. A few brilliantly chatted to their casualty while checking that the area was safe, finding out the problem, treating the injury and phoning 999.

5 6-year-olds appropriate actions during scenario checking for safety alerted an adult in an unsafe situation or if someone is hurt Know that hot materials burn treated a burn with cold water called 999 in the emergency situation Without support 73% 34% 89% 59% 52% With support 15% 14% 0% 28% 34%

7 8-year-olds Without support not covered not covered in assessment 97% 73% 80% With support not covered not covered in assessment 1% 14% 15%

table 7 results of retention assessment scenarios for pupils aged five to six and seven to eight One child who had problems with number recognition stated: I know I must call 999 but I cannot recognise the number as he held the mobile phone in his hand. Clearly he had no problem with verbal communication, so once he had got through to the operator he was able to pass on the information. He had conceptualised the need to call the emergency services but lacked the number skills to enable him to do so.

appropriate actions during scenario with an unconscious casualty tilted head back checked breathing put the casualty on their side With their head back called 999 answered the initial questions in a 999 call

7 8-year-olds Without support 20% 22% 52% 20% 80% 100% With support n/a 66% 45% 71% 15% 0%

9 10-year-olds Without support 36% 57% 69% 15% 81% 100% With support n/a 38% 30% 64% 19% 0%

table 8 results of retention assessment scenarios for pupils aged seven to eight and nine to ten

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Transcript from Retention Assessment

Emergency operator: Is he breathing? Pupil: Oh, I forgot. Ill tell you in a second. Pupil checked the breathing. Pupil: Yes.

Sixty-three per cent of seven to eight-year-olds and 78 per cent of nine to ten-year-olds knew if a breathing person was not moving or responding and they were on their back they were not in a safe position. There were significantly more children aged nine to ten than aged seven to eight that opened the airway and checked the breathing of the unconscious casualty. This could be due to the older children being able to remember more or that they

have a greater understanding of the need to breathe and the problems of a blocked airway. Over half of all the children remembered to put them on their side and this was higher in the older children but the difference was not significant. The problem arose in them remembering to put the casualtys head back. However when the pupils were prompted during the 999 call the vast majority then remembered what they had been taught and tilted the head back with ease.

Figure 10 treatment for unconsciousness nine to ten-year-olds

lO3a then put them on their side 69% took appropriate action 30% took appropriate action with support 0% took no action 1% took inappropriate action

lO3b with their head back 15% took appropriate action 64% took appropriate action with support 21% took no action 0% took inappropriate action

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The children aged seven to eight who did remember to tip the head back were mainly from one school where the difficulty in learning this aspect had been recognised and steps had been taken to overcome the difficulty e.g. additional explanations, repetition of practical work. The research shows that, if the child has learned some first aid skills, they can treat burns and bleeds, and recognise a breathing, unconscious person and put them in the recovery position with a little prompting from an emergency operator.

The recall of how to treat a nosebleed was disappointing. Just over a third of the nine to ten-year-olds taught this asked their casualty to lean forward and pinch the lower end of their nose (the correct action). A slightly higher percentage of children put the head back (incorrect). This could be for a variety of reasons. It is possible the lesson was too packed with topics, giving insufficient time for the children to process the information and fix it securely in their long-term memory. Perhaps more time was needed to overcome inaccurate prior learning.

The treatment for choking was better remembered, with well over half hitting the casualty between the shoulder blades. The influence of films was shown with the pupils who took inappropriate action by going straight to abdominal thrusts. When asked why, many commented that they remembered having seen this action in Mrs Doubtfire and other films. If this method of learning could be harnessed for the most effective treatments it would be very useful. As can be seen from the pie chart the intervention for severe bleeding was also well remembered.

Figure 11 treatment for choking and Bleeding

lO8 when blood is flowing from a wound (which is too large for a plaster) put pressure on it with whatever is available 75% took appropriate action 14% took appropriate action with support 9% took no action 2% took inappropriate action

lO9 if a person is choking hit them firmly on the back

62% took appropriate action 12% took appropriate action with support 20% took no action 6% took inappropriate action

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control group
Care needs to be taken with these results as there were very few children in the control groups. Thirteen seven to eight-year-olds did the scenarios. Nineteen were shown the scenarios and wrote or drew what they would do. Fiftyeight per cent of seven to eightyear-olds knew that a burn should be cooled, compared to 72 per cent of those who had been taught. However none of the control group knew to put an unconscious casualty on their side, compared to 52 per cent in the taught group. Twenty-four nine to ten-year-olds did the scenarios. Seventeen of took appropriate action took inappropriate action

taught group 62% 6%

control group 44% 30%

table 9 comparison of taught and control groups choking these were part of a group who were taught the first lesson but were absent or not taught lesson two. Similarly to the younger pupils none of the seven in the nine to ten-year-old control group knew to put an unconscious casualty on their side. Seventy per cent asked the casualty to take the wrong action for the nosebleed and 26 per cent did nothing. Fortyfour per cent correctly got pressure on the wound on the arm, while 30 per cent took an inappropriate action like wiping the wound. As the table above shows when treating their choking classmate 30 per cent of the control group would have gone straight to abdominal thrusts if they had not been stopped by the researcher. When asked why their reply was they had seen it in a film.

Figure 12 comparison of taught and control groups casualty unconcious and breathing

control group (aged nine to ten) 0% took appropriate action, turned onto side 86% took appropriate action with support 0% took no action 14% took inappropriate action

taught group (aged nine to ten) 69% took appropriate action, turned onto side 30% took appropriate action with support 0% took no action 1% took inappropriate action

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parents response

Some of the children were clearly passing on the messages they have learned. This evidence would indicate that by teaching the children first aid there may be an influence on the attitudes of a wider group of people. A number of parents suggested that the first aid skills should be reinforced in later years at school and a number wanted a booklet sent home.

problems encountered
Relatively few problems were encountered, mainly due to schools being extremely helpful and considerate. Inevitably occasionally things arose which delayed or stopped lessons, observations or retention assessments. The announcement of an Ofsted inspection took place number of questionnaires returned percentage returned

during the initial meeting at one school but to the schools credit this did not delay the process. Ofsted also complimented the school on taking part in the research. The teachers tended to adapt if there were problems by rearranging the lessons. On one occasion a year 5 trip had been arranged on the day scheduled for the retention assessment. This meant that the only year 5 children available were those who had not gone on the trip, which may have slightly biased the results for that particular school but will have had little effect on the overall results. Two teachers did not have time to teach the second lesson. The children in these classes were used as part of a very small control group in the retention assessments. A couple of classes did a quick revision session with the teacher before the retention assessment 172 30% 98% 78%

which may have had a minor effect but most of the teachers made a point of stating that they had not done any specific reinforcement with their pupils. First aid topics may have been mentioned if they cropped up as part of another topic being covered e.g. safety. This would be the normal part of teaching any curriculum subject and this would be one of the advantages of the class teacher having ownership of developing first aid knowledge. Many classes contained mixed age groups. In consequence, in addition to the age groups we were studying, there were often older pupils in the classes. In these cases it was impossible to distinguish between the different age groups during observations. This appeared to make no difference to the teaching or learning of the children of the age group involved in the research. The sample in the retention assessment came from the appropriate age range. A few teachers forgot or were unable to send the parent questionnaires home or return one of their own questionnaires. For details of the return of teacher questionnaires see appendix one.

Believed it is important their child learns first aid talked with their child about what they had learned Believed their child would cope better in an emergency following the lessons table 10 results from the parent questionnaires

not talked before with their child about what to do in an emergency 38% 82%

caSe StUDY
in this school pshe (personal, social, health and economic education) was organised and delivered by teaching assistants. they were clearly highly valued members of the school community. Frequently in primary schools teaching assistants or support staff care for injured or ill children. they are the ones the children chat to in the playground and they often have a first aid qualification. this does not necessarily make them better at teaching the simple first aid messages but they often are more confident about the subject matter. the link between having the knowledge to give first aid and actually doing it is clearly made. First aid being part of the caring and supportive approach aspect of the school community ethos is also clearly demonstrated. in this school, with children from a wide mix of ethnic groups, the first aid lessons were ably taught and greatly enjoyed by all.

Parent comments
My son made me pass out, checked my airway and then put me into the recovery position. I was amazed how much valuable information she took on board. I think that she will be able to cope with more confidence if there is an emergency. It should be compulsory for all children to learn about first aid.

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CONCluSiONS
can children learn first aid?

hildren can not only learn first aid from the age of five but enjoy learning it. There appears to be a number of reasons for this. The children can relate it to their own life and many of the children involved in the study used it as an opportunity to talk enthusiastically about their own experiences. The children, the teachers and the parents consider it relevant and many of the latter two groups admit to having learned from the sessions undertaken as well as the pupils. First aid learning can also use a variety of activities from practical to written group work and it can be very visual. The latter enables children with limited written English skills to access the learning relatively easily.

Which topics to teach and when

The topics covered in the research were appropriate for the age groups. Those covered in the earlier school years burns and emergency calls were chosen as they are relatively straightforward. There was no time in the study to cover any further topics, but the simple nature of the treatment for nosebleeds would suggest this is another topic that could be taught early. This would be useful as it appears many children are picking up first aid myths (e.g. putting the head back to treat a nosebleed) and it is difficult to unlearn these. Most pupils are unable to tell the time at this stage therefore cannot learn to put a burn under cold water for ten minutes but are able to build on their knowledge in later years. The ability to make a call to the emergency services opens a considerable support mechanism to a child. Given the permission to do so and the information of when and how to do it gives the child the confidence to phone. This will increase the resilience of the child considerably. The vast majority of children from the age of five are able to develop these skills. The nine to ten-year-old children took more appropriate actions than their younger colleagues when dealing with unconscious casualties, possibly because of their greater understanding of breathing and unconsciousness. It might be better to cover other first aid topics with the younger age groups and leave unconsciousness until the later years of primary education.

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The limited control group would indicate that unless children are taught about unconsciousness at school they are not going to be aware of the simple interventions that need to be taken to save a life. With the problems of drug and alcohol abuse in young people, and in some cases parents, unconsciousness is something that a number of students will encounter. (British Red Cross Propensity to Act/Life. Live it. survey 2010) Choking is another problem that children encounter and can learn the appropriate intervention. This, along with severe bleeding, has been shown to be a suitable topic for the middle and later years of primary education.

clear, simple messages

In some cases in the middle and later years of primary education pupils remember the key messages better if they understand the reasons behind the treatment, even if they do not remember the reasons e.g. tilting the head back to remove the tongue from the airway. Experience has shown that if the first aid messages are too complicated people lose confidence in being able to give first aid. It is therefore vital that the messages are kept simple and, both for this reason and the age of the children, it is vital any resource for primary school pupils is based on clear, simple messages. It should therefore be

based on an outcome-based approach to first aid, highlighted in the introduction. However a balance needs to be struck between explaining the reasons behind techniques to enable understanding and help recall and keeping the messages simple. An element of explanation will also integrate the first aid into some aspects of the primary curriculum like science.

the feasibility of schoolteachers teaching first aid

All the schools involved in the study said they would teach the topics again the following year, now they had the resources and had seen the value of the learning to the children. There is no doubt that the primary school curriculum is packed with many subjects but the relevance and flexibility of first aid allows it to be both incorporated into other subjects and learned as a standalone topic over relatively short periods of time. With younger children, who have short concentration spans, a classroom teacher can interweave the first aid with other learning activities. If teachers teach the first aid they are probably more likely to revisit the topic in related topics and so consolidate the learning. There is an important place for external organisations like the British Red Cross going into

Figure 13 powerpoint slide for pupils aged seven to ten 26

riGht place, riGht time First aid education in primary schools

schools to teach first aid but they cannot hope to cover all topics and reinforce and progress them in the same way as the classroom teacher. Neither can we hope to have enough educators to go to all the schools that would want them, or the funds to support the programme if the schools do not have the budget to contribute. The classroom teacher and the school taking ownership of the topic would mean that it was integrated into the curriculum and thus reinforcement and progression would take place. This study has shown that teachers can be extremely successful in teaching first aid and ensuring that all members of the class regardless of ability, background or behaviour can learn some skills and knowledge. They are also excellent at devising ways of reinforcing the simple messages through fun ways of rehearsal or repetition. One group of teachers suggested their pupils take up the nose-bleed position when they wanted the class to be silent after a group work activity.

clearly. First aid is also an excellent way to develop other skills like considering and supporting others.

Retention of skills
All the age groups studied retained their skills and knowledge to a large extent, whether it was to put an unconscious person on their side, apply pressure to a severe bleed or phone 999. This shows that pain reduction or even life-saving skills can be learned throughout a childs time at school with relatively little investment of time. The majority of children could remember how to call the emergency services, and treat burns, choking and severe bleeds. Many of those that forgot initially remembered with slight prompting e.g. by the emergency operator. They were then able to confidently undertake an intervention that a child who had not been taught first aid did hesitantly and less effectively. If this is the case in the relatively unpressured situation of a retention assessment, it may enable a child in an actual emergency situation to undertake an action that without previous experience they would not do, even with telephone support. That is assuming they would have phoned 999 in the first place without the encouragement of previous learning in this area. Learning how and when to make a phone call to the emergency services is clearly a very important aspect of first aid education. Although the teachers believed that a high percentage of the children had learned to put an unconscious casualty on their side with the head back, by the time the retention assessment was undertaken most forgot to open the airway. This is comparable with Bolligs study of six to seven-year-olds in which the retention assessment took place

Figure 14 pupils poster

Using first aid to deliver other skills

There is also a strong argument for a classroom teacher to use first aid as a vehicle to develop other subjects such as literacy and science as it can be motivating, relevant and, in some cases, a familiar subject. The example of the story produced by a child in one of the research schools in the key findings section shows this

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six months later, as well as Isbyes study with young people aged 12 to 14 in which the assessment took place three months after the learning (even with adults in this study it was much lower than the number of people who checked for breathing). A couple of teachers commented that this was an area that had to be reinforced at the time of teaching to ensure the children remembered this aspect.

give help if there are other people present (Darley, J.M. & Latan). This could be an interesting area for further research. Generally as children get older many develop inhibitions that are not there earlier which could contribute to the bystander effect. If, before the inhibitions start to develop, young people believe they can, and should, give first aid, the propensity to act in an emergency in the general population may increase. The childrens own resilience should also be higher. Despite often being nervous, the children undertaking the mock scenarios showed a desire to give of their best to support their injured colleague. A very few were able to chat away to the casualty checking what had happened and reassuring them but the vast majority were concentrating hard on remembering what to do. In this aspect they were very successful and also very proud of what they achieved. Studying first aid gives all children the opportunity to experience success while developing their resilience.

Reinforcement and progression

Though it was very pleasing how much the pupils remembered after two months it will be important that the skills are reinforced and progressed over a childs time at school and throughout their life. Bollig recommended a four-step model of first aid education. An adapted version of this could be relevant for the UK education system: As peoples lives change e.g. they take up different sports, have children, their parents become elderly, they could revisit the first aid they have already learned and add on additional skills relevant to their lives. If we start the process of learning first aid as early as possible we will build a much more resilient society. The individuals that make up this society may also be more confident and willing to act to support each other.

childrens confidence and desire to help

The childrens view as to whether they would help an injured person was very high among the youngest. Whether the reduction in believing they were going to act among older groups was due to age, topic or something else is difficult to know. This may indicate that the earlier people are taught first aid the more likely they are to believe it is normal behaviour to help others in this way. It would be interesting to see if the belief that they would act was maintained into adulthood and whether this reduces the bystander effect in the general population. The bystander effect is where people are less likely to

Four-step model of first aid education adapted from Bollig

step 4 Repetition and progression of life-supporting first aid and extended first aid as appropriate to the persons lifestyle and stage in life (from 16 years old) step 3 life-supporting first aid and extended first aid as appropriate to a persons lifestyle (from 16) step 2 life-supporting first aid For all young people in secondary school (aged 11 to 16), including cpr

step 1 Basic first aid For all children in primary school (age five to 11) starting at age five Knowledge and skills to be revisited, progressed and added to as the pupils move up the school.

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caSe StUDY
some weeks after his first aid course one ten-year-old boys younger brother severely cut his lower arm on a sheet of glass. remembering that it was important to alert an adult under these circumstances he opened the front door and ran out yelling help. a gasman working over the road came to his support. First aid was given to stem the bleeding and an ambulance was called. When the father came up to the school to thank them for their part in the rescue he commented that if his son had not had the lessons in school it would not have ended so happily.

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RECOMMENDAtiONS
Recommendation 1
Simple first aid should be taught to all ages. Children as young as five have been shown to learn and retain first aid skills, regardless of demographics like gender, ability, primary language, mobility, social and ethnic background, and behaviour. The desire and ability to develop first aid skills is evident and continues throughout their primary school career. As they grow older and gain more responsibilities and interests, their first aid knowledge should be expanded as appropriate. > safety > contacting the emergency services > burns > nosebleeds Additional topics should be added as the child gets older. Simple first aid actions do not take long to learn but are relevant to all children and develop their resilience. In starting the teaching of first aid as early as possible we may prevent adults developing the inhibitions to helping others that can result in the bystander effect. People should see first aid as second nature. It should support the development of a can do and a will do society.

Recommendation 6
teachers should be able to access support to increase confidence to teach first aid. Some teachers are hesitant to teach first aid, for a variety of reasons. In many cases, being able to access appropriate and supportive teaching materials will be enough to give them the confidence to introduce the topic into the curriculum. Some teachers will want an introduction to appropriate materials or a more detailed workshop to build their understanding of, and confidence in, the content and approach.

Recommendation 2
First aid should become as natural a part of life as counting. By teaching first aid starting in the year pupils are five, first aid knowledge and helping others could become integral to a childs life and hopefully continue into adulthood. In the early school years children start to look outside themselves and are taught about caring for and supporting others, taking responsibility for themselves and those around them. First aid needs to be introduced into the curriculum at this early stage, both for its own sake and also because it is an ideal vehicle through which these approaches to life can be taught.

Recommendation 7
First aid should be included in the statutory primary school curricula in england, Northern ireland, Scotland and Wales. First aid being made part of the curricula in the four countries will ensure virtually all children will have basic first aid knowledge and skills. This will encourage responsible and caring behaviour, make children more resilient and reduce pain in injured people through quick, appropriate treatment. In the long term it could lead to more resilient adults. It will also save lives. A programme consisting of relatively short sessions, right across the U.K., could have a large and lasting impact.

Recommendation 4
all children should be taught how and when to phone the emergency services as early as possible. Being able and sufficiently confident to contact the emergency services opens a massive support network for a child and enables them to act and recall skills that have slipped their mind.

Recommendation 5
teachers should be able to access first aid teaching materials. With the demands on all teachers time, materials are needed to provide all the information and activities to enable the pupils to learn first aid and give the teachers the confidence to teach it with minimum preparation. To make it feasible for all teachers to teach first aid the materials need to be easily accessible and affordable, ideally free.

Recommendation 3
Simple first aid messages should be reinforced and childrens confidence developed over their time in primary school. As a minimum, the following topics should be taught within the context of caring for and supporting others and oneself in the earlier years of school: 30

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REfERENCES
Amy Binley Avonsafe Report British Red Cross July 2010 Paul Bradshaw, Sue Frankfort Crucial Crew Evaluation Oswestry 2009 British Red Cross Georg Bollig, Hans Alvin Wahl, Martin Veel Svendsen Primary school children are able to perform basic life-saving first aid measures Resuscitation March 2009 J. Breckwoldt Starting at school. An approach to improve resuscitation outcomes. Notfall Rettungsmed 2009 Suppl 2 12:39-44 DOI 10.1007/s10049009-1209-y British Red Cross Life. Live it. The case for first aid education in UK schools September 2006 British Red Cross Propensity to Act/Life. Live it. survey 2010 British Red Cross Life. Live it. First aid education kit The Cormac Trust The ABC for Life programme was launched in February 2006 at Queens University. Darley, J.M. & Latan, B. (1968). Bystander intervention in emergencies: Diffusion of responsibility. Journal of Personality and Social Psychology, 8, 377-383 DJS Research Ltd. Primary First Aid Education British Red Cross August 2010 First Aid Education, Department British Red Cross (2010) Teaching first aid: the key skills approach. Roman Fleischhackl, Alexander Nuernberger, Fritz Sterz et al School children sufficiently apply life supporting first aid: a Prospective investigation. Critical Care 2009 13:R127 K Frederick, E Bixby, M-N Orzel, S Stewart Brown, K Willett An evaluation of the effectiveness of the Injury Minimization Programme for Schools (I.M.P.S.) Susan E. Gathercole & Tracy Packiam Alloway Working Memory and Learning A practical Guide for Teachers 2008 Sage Publications IFRC First Aid for a safer future Focus on Europe Advocacy Report September 2009 Ian Jones, R. Whitfield, M. Colquhoun, D. Chamberlain, N. Vetter, R. Newcombe At what age can schoolchildren provide effective chest compressions? An observational study from the Heartstart UK schools training programme. BMJ, doi:10.1136/ bmj.39167.459028.DE (published 27th April 2007) Wayne Morgan Keep Me Safe Report British Red Cross 2006 P. Nuttall (1991) Primary child development National Network for Child Care. Amherst, MA: University of Massachusetts ZakariassenE., Andersen J. E., Frstehjelp for 1. klasse. Scand J Trauma Resusc Emerg Med 2004;12:162-5

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AppENDix
Although not all the teacher questionnaires were returned there were enough to enable valid conclusions to be drawn. Number of questionnaires returned age of children (years) 5/6 7/8 9/10 Number of classes 7 8 9 lesson 1 7 5 7 lesson 2 6 4 4

table 3 number of teacher questionnaires returned

SpECiAl thANKS
Many thanks to all the staff and pupils at the schools who gave so enthusiastically of their time and expertise and enabled this research to take place. Sincere thanks also to those who provided ideas, advice and materials without which the project would have fallen at the first hurdle: Liz Brunwin Alison McNulty Ruth Caldeira Joe Mulligan Andrew Farrar Wiebe de Vries Amy Binley Wayne Morgan Geoff Cooper John Pollard Lynda Roberts Charles Williams

Figure 15 last powerpoint slide in the last presentation for all classes

photo credits are listed from left to right, in clockwise order Brc Front cover: alex rumford, inside Front cover: alex rumford, page 1: dominic cocozza, page 3: alex rumford, page 4: alex rumford, page 5: alex rumford, page 6: (top) alex rumford, (bottom) www.imagesource.com, page 7: alex rumford, page 8: alex rumford, page 9: alex rumford, page 11: alex rumford, page 13: steve Gorton, page 14: Brc, page 15: alex rumford, page 25: alex rumford, page 26: alex rumford, page 27: alex rumford, page 27: alex rumford, page 29: (top left) alex rumford, (bottom right) dominic cocozza, inside Back cover: lloyd sturdy

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riGht place, riGht time First aid education in primary schools

riGht place, riGht time First aid education in primary schools

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British red cross uK office 44 moorfields london ec2y 9al the British red cross society, incorporated by royal charter 1908, is a charity registered in england and Wales (220949) and scotland (sc037738)

redcross.org.uk